This invention relates generally to the field of quality control review medical treatment and, more specifically, to a system for gathering and evaluating data on the delivery of medical care for ambulatory patient visits. In this application, the term "medical" is used in its broadest sense which encompasses the health related activities and knowledge of all health professionals including, but not limited to, doctors, dentists, other licensed health professionals, and those in the allied health professions.
A major economic problem that has risen during the past twenty years has been the upward spiraling cost of medical care. Demographic factors have played one role in this increased cost since extended life expectancies increase the percentage of older individuals in the population. Generally, such individuals require a much higher degree of medical care. A second major factor contributing to increased costs for medical care has been the advent of many new, expensive, medical procedures which have sprung from medical and instrumentation advances of the past ten years. More widely known examples are organ transplants and the use of CAT scanners or MRI units for routine diagnosis. An additional factor has been the increased rate of inflation, which has dramatically influenced the costs for drugs.
Due to all of the above, as well as other factors, the cost of even routine medical care has increased dramatically. Correspondingly, insurers of medical care have had to increase their charges dramatically in order to offset these much higher costs. The insurer of the largest group in the United States, the Health Care Financing Administration, which administers Medicare, has been particularly susceptible to the dramatic increases since Medicare provides coverage primarily to those individuals who have reached their sixty-fifth birthday. After a few years experience with the Medicare program, Medicare administrators became aware of the fact that many of the charges being submitted by medical care providers were excessive, if not outright fraudulent. This has led to a system of quality review of the professional performance of medical care providers participating in the Medicare program and has resulted in criminal prosecutions in addition to civil actions against offending professionals.
In order to better control the rising hospitalization costs for the elderly, a hospital admissions and treatment review program was instituted by Medicare to evaluate the appropriateness of the care given to Medicare recipients at hospitals. Concerns over quality of care have thus also become concerns that unnecessary medical treatment is being given to patients for which the insurer is being billed. Such unnecessary costs must be reflected in increased insurance premiums. This review program has been implemented in all states within the United States, and has resulted in significant savings for unnecessary hospitalizations, unnecessary treatments, and overly-long hospital stays. This Medicare review program has become a model program by which hospital admissions and procedures are also being evaluated nation-wide by private insurers. While the current standards for appropriate treatment of Medicare patients in hospitals are set by each state, there is evolving a national consensus towards what constitutes appropriate medical care. Not only are each state's standards available for review and discussion by the standard setting organizations of other states, but also private insurers are generally utilizing the same standards which the Medicare state review agencies have devised. It is probable that such national use will ultimately lead to a uniform set of standards across the United States for hospital admission and treatment of both Medicare recipients and privately insured individuals. Quality review of hospital admissions and treatment was chosen for initial review for two reasons: (1) hospitalizations represented a significant faction of the total dollars expended by the Medicare system; and (2) hospital procedures and record keeping made review of cases relatively straight forward and accessible.
Private insurers have followed the government's lead in attempting to reduce hospitalization costs by requiring their insureds to obtain prior approval from the insurer for non-emergency hospitalizations. Virtually all insurers in the United States have adopted a system whereby an insured is required to contact the insurance carrier prior to non-emergency hospital admission. The insurance carriers have developed screening procedures and minimum criteria, which they believe weed out unnecessary hospitalizations for their insureds. Whether the actions by the private insurers have been as effective as actions by Medicare is unclear since they lack the statutory enforcement authority provided Medicare. For instance, any doctor or hospital found in violation of the Medicare standards may, after an appropriate opportunity to correct their behavior, be expelled from the Medicare system. For both doctors and hospitals, expulsion means a major decrease in their patient base with loss of concomitant funding, which very few doctors or hospitals can afford. Thus, the Medicare restraints work directly on the doctors and the hospitals. On the other hand, private insurers must attempt to enforce quality review procedures and cost controls through the only persons with whom they have contracts, their insureds. Insurers hope that by refusing to pay for what they believe are unnecessary procedures and hospital admissions, which results in their insureds paying for a higher percentage of such costs, they will dissuade their insureds from utilizing those doctors and hospitals providing the unnecessary medical care. Neither the quality review procedures used by Medicare nor those used by private insurers addresses the issue of quality review of the medical services provided to ambulatory (office visit) patients. Since this represents the other major cost of medical care, it represents an area for potentially great savings to the insurance systems.
However, implementation of a nation-wide quality review system covering services rendered to ambulatory patients has not heretofore been attempted due to the overwhelming number of patients and patient visits involved. While there is a large number of admissions based upon hospital capacity, there are hundreds of times more doctors and other medical care providers than hospitals. Each doctor and medical care provider in turn may have several thousand patient office visits per year. Medicare has been directed to have in place by 1992, a quality review system for ambulatory care. At the present time, it is anticipated that such a system will be based upon a traditional "chart audit" in which patient charts will be randomly selected from medical care provider's offices for individual review by a quality review evaluation panel. Not only will there be problems with the statistics of such a review, but to date, no chart audit criteria had been developed or proposed by Medicare for implementation with such a system.
Any attempt at quality review of every ambulatory visit under the current system of insurance administration is impossible due to the paperwork overhead. In current reimbursement systems there is a multiple stage process which is required before a medical care provider is paid by the insurers for services rendered, whether the insurer is the government or a private entity. The multiple stage paperwork generating processing is a burden for the medical care providers, the insurer, and the patient. Typically, for instance, the patient is required to fill out part of a medical care form prior to submission of the form to the medical care provider. The medical care provider must then add its data to the form, and either the provider or the insured must then forward the form to the insurer. The insurer must review the material, verify coverage, and determine whether the charges should be paid. Only then does the insurer issue a draft to the medical care provider or the insured, as the circumstances of the insurance contract warrant. Under current practice, quality review by a private insurer is only possible at the end of a burdensome data gathering process. More often than not, it is necessary for the insurer to obtain additional information, either from the insured or from the medical care provider in aid of making a quality review determination. The multiple levels of paper work require the expenditure of significant time and effort by all parties involved which itself increases the cost of insurance as well as over-burdening the system at all levels with administrative overhead.
Private insurers have also not implemented, and have no immediate plans to implement, any type of quality review of ambulatory patient care. As mentioned above, the large number of patient visits, including repetitive visits by the same patient for the same problem, as well as the possibility that patients may seek care for any number of medical concerns during a typical year, make the likelihood of assessing the total adequacy and quality of care being rendered to ambulatory patients by a chart audit process nearly impossible. Indeed, a patient may see more than one medical care provider for the same medical problem, with or without notice to the providers. Thus, a review of a patient's chart from one provider's office may still not yield a clear picture of the quality of care being delivered to that patient.
While eliminating unnecessary treatment is the initial goal of such quality review procedures, it is quite clear that down the line one additional benefit will be the ability to ascertain that all patients are receiving the appropriate and complete medical care for which the insurance system is paying. However, for providers and patients already overwhelmed by a system of insurance forms and record keeping, a comprehensive ambulatory review system which imposes additional paperwork demands would not likely produce the desired information due to resistance by both the patients and the providers to dealing with yet another level of bureaucracy.
Ideally, any quality review procedure examining the care given ambulatory patients would track all patient visits to medical care providers.